+LOVE

+LOVE is an integrated case management intervention with behavioral health and crisis support to enhance and improve HIV care and outcomes for Black gay, bisexual, and other men who have sex with men. The intervention includes a dedicated case manager, behavioral health therapist, and a text message-based engagement service that provides medication reminders and assesses participants’ basic needs and levels of anxiety and depression. A triage crisis coordinator is also available to respond to alerts and offer immediate crisis assistance. This 12-month intervention was implemented by CrescentCare, a Federally Qualified Health Center (FQHC) in New Orleans, as part of a Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) initiative. An evaluation of +LOVE showed improvements in retention in care.

New Orleans , LA

Implementation Guide
False
Evidence-Informed Intervention
Icon for Intervention Type
Support service delivery model; Use of technology and mobile health
Icon for HIV Care Continuum
Retention in HIV medical care; Beyond the care continuum
Icon for Ending the HIV Epidemic in the U.S. Strategy
Treat
Icon for Focus Population
Black gay and bisexual men; Black/African American people; Gay, bisexual, and other men who have sex with men (MSM)
Icon for Priority Funding
RWHAP Part F SPNS
Icon for Setting
Community health center, including Federally Qualified Health Centers (FQHCs); RWHAP-funded clinic or organization
Need Addressed

In New Orleans and Louisiana overall, Black gay, bisexual, and other men who have sex with men with HIV face disparities in linkage and retention to HIV care, and viral suppression. Examining client data for 2017, CrescentCare found that 62 percent of Black clients who identified as gay, bisexual, and other men who have sex with men were retained in care compared to 73 percent of their white counterparts. Similarly, 78 percent of these Black clients reached viral suppression compared to 86 percent of white clients.

Black gay, bisexual, and other men who have sex with men are more likely to experience discrimination, housing instability, poverty, unemployment, and food insecurity because of societal marginalization. In addition, they are more likely than their white peers to have experienced incidents of health care mistreatment due to systemic racism. All of these social determinants of health affect access and adherence to HIV treatment. To address these determinants, CrescentCare designed +LOVE to be a culturally responsive intervention that considered the challenges and barriers to retention in HIV care for Black gay, bisexual, and other men who have sex with men. The intervention provided integrated HIV care, navigation support, and crisis support; linked clients to behavioral health resources; and promoted feelings of empowerment to overcome mistrust and fears related to prior mistreatment within the healthcare system.

Core Elements
Dedicated case management

A dedicated case manager worked with clients throughout their participation in +LOVE. The case manager screened participants to assess their basic needs, provided referrals to resources and assistance with health care coverage and housing, and functioned as a liaison with the participants’ medical case manager and HIV care providers. Interactions with participants were conducted through in-person appointments, phone calls, and text messaging directly to participants’ phones. By providing participants with a dedicated case manager who was familiar with the specific needs of Black gay, bisexual, and other men who have sex with men and a member of the community himself, +LOVE was able to secure the trust of its clients, leading them to seek more needed services and resources to improve their social and economic stability.

Behavioral health therapist

+LOVE provided enhanced psychological support to participants, addressed mental health needs that could act as barriers to HIV care and medication adherence, and helped diminish the effects of social stigma. A dedicated behavioral health therapist with extensive experience working with LGBTQ+ clients, people of color, and people with HIV offered “sex-positive therapy” with a focus on building self-esteem and harm reduction strategies. The therapy incorporated a social justice lens, strengthened by eye movement desensitization, reprocessing tools, and other trauma-informed techniques. The behavioral health therapist also taught and conducted mindfulness-based stress reduction, as well as provided guided meditation to participants. Upon enrollment, participants were also offered free therapy that they could access at any time over the course of their participation in +LOVE

Mobile health text messaging service

Additionally, clients were provided text-based mHealth digital support (CareSignal) that tracked their basic needs and levels of anxiety and depression, and provided ART reminders. CareSignal offered several types of tracking, which participants consented to upon enrollment, depending on their individual needs and comfort. Mood, depression, and anxiety tracking included receiving questions via text about mood changes and questions derived from the Patient Health Questionnaire (PHQ-9) scale for depression and the Generalized Anxiety Disorder (GAD-7) scale for anxiety; these scales include questions regarding suicidal ideation and suicidality. 

Medication tracking provided reminders to take medications at times pre-designated by the participants during enrollment; it also tracked adherence. Basic needs tracking, which included pre-determined social determinants of health indicators, followed participants’ basic needs, such as food, housing, and employment. Routine CareSignal assessments made it possible for the +LOVE team to track participants’ needs, mood states, and crises in real time, so that no participant’s situation could escalate to the point of interrupting their regular HIV care appointments and medication regimen.

Triage crisis coordination

The triage crisis coordinator, a licensed social worker, addressed and investigated all alerts that came through the text messaging system and determined what form of immediate linkage and support clients needed. The coordinator conducted crisis management and wellness checks with participants via phone calls and text messaging. For participants in crisis who needed therapy, the triage crisis coordinator provided psychoeducation as a means of encouraging them to make appointments with the behavioral health therapist. Additionally, the coordinator was able to provide a different form of behavioral health support to participants, in particular to those who were less likely to engage in traditional therapy. By having a triage crisis coordinator on staff, +LOVE ensured that resources and support were provided in a timely manner to prevent crises from interrupting HIV care.

“As soon as I put in something that something was off when answering the text messages, they were quick to reach out to me to see what was going on. I didn’t have to hunt for someone to help me.”

Other support services

+LOVE provided free Lyft rides to HIV and related care appointments to reduce transportation barriers. It also referred and encouraged participants to take part in The Movement, another program offered by CrescentCare. The Movement provided Black gay, bisexual, and other men who have sex with men with online and in-person peer support, social activities, and linkage to sexually transmitted infections testing, with the aim of building participants’ social support networks.

Outcomes

CrescentCare enrolled 146 Black gay, bisexual, and other men who have sex with men in the +LOVE intervention from October 2019 through December 2021, although not all participants used every component of the intervention. In total, the participants had 312 therapy appointments with the behavioral health therapist; the majority had never had behavioral health therapy before. An evaluation comparing outcomes between participants who accessed behavioral health services in addition to case management to those who just accessed case management, showed that the behavioral health services component contributed toward improvement in retention in care at both 6 and 12 months.

CategoryInformation
Evaluation data

Electronic medical record data and client surveys

Measures

  • Retention in HIV care, defined as having a routine HIV medical care visit in the last six months or as having two or more HIV visits within the past year
  • Participation in behavioral health services
Results
  • Clients accessing behavioral health services were found to have: 2.415 times higher odds of remaining engaged in HIV care within the past 6 months (p=0.009)* and 3.336 times higher odds of having attended two or more HIV-related medical visits in the past 12 months (p=0.002)* than those not engaged in behavioral health services. 
  • After 12 months, 55 (38%) participants had received behavioral health therapy through +LOVE up from 25 (17%) that had received behavioral health therapy prior to their enrollment. Of these 55 accessing behavioral health services through +LOVE, 42 (76%) had not received behavioral health services at baseline.

*statistically significant 

Sources: Barak N, Boyle C. Lessons from +LOVE, improving HIV Care for Black men who have Sex with men in New Orleans using an integrated behavioral health crisis support model of care. AIDS Patient Care STDS. 2022;36(S1):S65–S73.  NORC at the University of Chicago. Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes for Black Men who have Sex with Men Initiative Monograph. (2022).

“It has helped in a way that helps to remind myself to take my pills, to check in with myself about how I’m feeling. Take more stock with myself.”

Planning & Implementation

Case management. Participants were given the option to either remain with their current case manager or to work with the +LOVE program's dedicated case manager. The +LOVE case manager had a caseload about half the size of the typical caseload at CrescentCare. He also had been working with Black gay, bisexual, and other men who have sex with men in the community, self-identified as a Black gay man, and worked closely with other staff on the +LOVE team. Finally, unlike other case managers, he could offer participants free Lyft rides to HIV care and related appointments through a component of +LOVE program grant funding. 

Outreach and recruitment. +LOVE used various approaches to recruit participants including: 1) contacting current clients at CrescentCare; 2) visiting venues and attending events at bars, clubs, and agencies where a large proportion of attendees were Black gay, bisexual, and other men who have sex with men; 3) posting ads on dating apps; 4) posting ads at bus stops and on buses in neighborhoods and on routes where people eligible for +LOVE were known to live, visit, and travel through; 5) sending digital flyers to other health facilities in the city; and 6) promoting peer-to-peer referrals through current participants.

Opt-in options for tracking. At enrollment and based on their needs, clients indicated what types of tracking and assessment they wanted through CareSignal, the text-based messaging service. If they chose anxiety and depression tracking, they received periodic text messages with questions about anxiety (GAD-7) and depression (PHQ-9). If they chose medication tracking, they received reminders to take their medications at times they designated would work. If they chose basic needs tracking, they received queries regarding help they needed.

Lessons Learned
  • +LOVE staff’s prior establishment of routine check-ins in person and through text messaging mitigated the COVID-19 pandemic’s detrimental effects on clients’ health, mental well-being, and access to medication, food, and housing.
  • People with HIV may be more hesitant to access behavioral health care services than others. Therefore, the referral process may benefit from a psychoeducational component that helps to destigmatize these services. Additionally, the types of behavioral health services offered should be tailored to participant desires and needs.  Traditional in-person, once-a-week therapy may not be the most effective way to provide behavioral health therapy and/or crisis support.
Contact
CrescentCare
Gabriel Vander Hey
Reginald Vicks, BSN, MBA

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